Daniel Menaker

Onconversations XXXI

Monday, April 23, 2012

(I talk to my main oncologist on the phone, after my radiation treatments are over and after he and I have exchanged emails about the follow-up CT scan three months later. [See ONCONVERSATIONS XXX])

ME: So I potentially have this job offer coming my way. Can you imagine–at seventy, cancerous, mildly diabetic, with no thyroid function. But I don’t know what to do about this, because of my lung situation. I’d like to renovate the big barn behind our house in the country, or at least shore it up. So the money would be nice.
DR: Just do what you want to do.  The last time we wrote, you were saying something about an investment decision. Is this the same thing?
ME: No–this is something different. One had to do with maybe selling a stock that had done well and this one has to do with a possible job offer. But they both raise the question of How Long.
DR:  We can’t know, but in my opinion, long, unless something else gets you first.
ME: Well, you still haven’t answered my earlier question about similar cases: recurrent small malignant lung nodules, same lung, isolated, indolent, no evidence of mets.
DR: “Mets,” eh? You’re learning the slang.
ME:  All these abbreviations–you have to have them because so many of the words and phrases are so long.  Chemo, IV, SBRT, QOL, dexy–
DR: “Dexy”? That’s dexadrine. You didn’t have dexadrine.
ME: Well, I thought I had made that one up. It was supposed to be for “dexamethasone”–that steroid I took when I was on chemo. I mean chemotherapy.  But back to the outcomes in cases like mine, please–people in more or less my situation who have chosen stereotactic body radiation therapy over surgery.
DR: I can think of a few comparable cases. One guy, a CEO, is walking around happily seven years after being treated.  Another person, a woman, is four years out.
ME: Are you repressing less favorable results?
DR: Probably.
ME: Oh, great. You don’t know? Or are you suppressing
DR:  In the last year alone, we’ve found new ways of treating your condition, if it gets worse.
ME:  Good! What?
DR: Some of my patients tell me, “All you have to do is keep me alive for a few more years and you’ll find something new to work with.” And sometimes they’re right.
ME: Great! But, you were saying “in the last year alone”?
DR:  Yes–remember we found that you have this mutation–EGFR–but it didn’t seem susceptible to Tarceva, the targeted therapy for some lung cancers. It didn’t have the right structure?
ME: How could I forget? That was the low point, I think. Although it’s the abbreviation that gave me my most impressive medical terminology–epithelial growth factor receptor.
DR:  Excellent! Well, there are further findings that suggest strongly that Tarceva is applicable in your case. Which would be a very good thing if and when we have to do more.
ME: Well, that’s extremely encouraging.
DR: Yes. I really am encouraged, as I said in my emails.
ME: Why didn’t you tell me about this Tarceva news earlier?
DR: There was no point–you were having SBRT.
ME: So you kept it on the QT.
DR: Very funny.  So I say, take the job, if it’s offered, and hold on to the stock, whatever it is.

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Onconversations XXX

Wednesday, April 18, 2012

(The following is a slightly redacted email exchange between me and my thoracic oncologist.)

ME: As I wait for the results of the follow-up CT scan I just had (which Dr. _______ [the oncology radiologist] says will likely show not much change, but I’m not counting on that in any direction–same, better, or worse), I wonder if I could make an appointment with you, or have a phone call, about a couple of questions I have which are sort of vague and maybe even loopy, and probably repetitive. One (not so loopy), for example, is:  If and when there is further need for treatment, whether without knowing more about these lesions–the more that you might have known if I’d had surgery–there are targeted therapies that you might consider using more blindly on the basis of what you do know, from the biopsies. Or would that be dumb? Also, have you treated patients like me, with recurrent small, relatively indolent multiple same-lung nodules who are in pretty good shape, around my age, who have had SBRT, and if so, what have been the outcomes? Yes, I am thinking again about Time Left, especially in view of some recent financial good fortune. Not Scrooge McDuck scale but nice enough.

I hope that you yourself are well, and I’m sure that one way or another, at one point or another, we’ll be talking again.

DR: Happy to discuss these questions.  Could talk on the phone Monday or Tuesday next week or see you in clinic next week on Wednesday.  If Scrooge McDuck has an “investment” decision that needs to be made sooner, I’m happy to try to find time sooner.

DR: [Later that day] I just looked at your CT scan.  It looks good.  From the report:  “Nodules in the left lower lobe are stable to minimally decreased.”  There are some changes which we can attribute to the radiation: “New adjacent focal subpleural ground glass opacity in the left lower lobe” and a “small loculated pleural effusion.” Altogether, it shows nothing of concern to me and some encouraging findings. Enjoy the weekend.

ME: Thanks very much for getting this information to me. I take it that the loculated pleural effusion is what remains of the earlier one–it showed up during the SBRT treatment but (clearly) wasn’t  serious enough to preclude the treatment, after the major portion of it was aspirated by Dr. _______. Also, Dr. _________ said that this partic. CT scan would probably not show much change but the next one might–one hopes in the direction of shrinkage or even obliteration. The next one is six months from now–is that correct.
These nodules seem really obdurate. Are they made of Kryptonite, or what?

DR: This exactly what we would expect to see if everything had gone perfectly.  There is no right answer on when the next scan is.  I’d say confirm with ________ when you see him–4 or 6 months would be reasonable.

(Despite the tricky grammar of that first sentence, I am of course very pleased to hear this news. Also pleased to learn this elegant new word–“loculated.”)

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Onconversations XXIX

Monday, April 09, 2012

(A spectacular spring day in a Riverside Park dog run, a cindery expanse where dogs are allowed off the leash and often stand around or sit around or lie around rather than run. Their owners stand around or sit around on benches and talk on their cell phones or talk to each other, almost always about dogs–a conversation both as limited and infinitely variable as the sonnet form. Example:

OWNER 1: What is she–some kind of hound, I think. Right?
OWNER 2: She’s some kind of mix–probably beagle and chow, with a touch of spaniel.
OWNER 1: Very pretty!
OWNER 2: Thanks. Don’t you think it’s funny when owners say thank you for a compliment  to their dogs?
OWNER 1: Well, they can’t.
OWNER 2: Who can’t?
OWNER 1: The dogs can’t say thank you. Somebody has to say it, I guess.
OWNER 2: Right- -Daisy, no chewing!
OWNER 1: They like that loose skin, like jowls, for instance.  I can’t let Maxwell play with any dog that has jowls or any kind of folds.
OWNER 2: Which one is Maxwell?
OWNER 1: He’s over there. That Jack Russell is trying to hump him.
(The Jack Russell’s owner, heard in the distance, shouts, “Angus, now you know better than that. He’s not interested.”)
OWNER 2: Hilarious!
OWNER 1:  So Daisy is a rescue?
OWNER 2: Yes.  From Arkansas. They bring them up in a van.
OWNER 1: There are a lot of rescues from Arkansas and the Carolinas and so on. I wonder why.
OWNER 2: I don’t know. Maybe more dogs are abandoned in the South, or something.  Maxwell is–what? A wheaten?
OWNER 1:  A Tibetan. A Tibetan terrier.
OWNER 2: He’s beautiful.
OWNER 1: Well, um–thanks! Ha ha. (Just a little defensively): You know we had a rescue before–Pepper.  When our kids were little.
OWNER 2: Hey–far be it from me to judge.
OWNER 1: You know, Tibetan terriers aren’t terriers.
OWNER 2: Really?
OWNER 1: No, it seems like when the British were pillaging Tibet or whatever they were doing there, they saw this temple dog and one of them probably said something like, “Nigel, look here: this dog looks rather like a terrier, don’t you think? I say, let’s call him a Tibetan terrier!” And Nigel said, “Jolly good, Freddy!” But they’re not genetically terriers. More related to Lhasas and Shih-tzus.
OWNER 2: Temple dog?
OWNER 1: Yes, they lead the monks to prayer, supposedly. But you know, you can’t sell or buy these dogs in Tibet. You have to give them or receive them as a present. They’re sacred dogs. He’s sacred to me because he doesn’t shed.
OWNER 2: Daisy sheds like crazy. She like leaves a wake in the early summer.

Etc.  So I’m in the dog run and run into a friend there whose wife has had a liver transplant because of liver cancer, or so I recall):

FRIEND:  Didn’t you have a CT scan recently?
ME: Today, in fact. Just this morning.
FRIEND: How did it go?
ME: Fine. The technician was very cheerful. Of course he didn’t tell me anything.
FRIEND: They never do.
ME: They’re like cheerful Sphinxes. They probably know more than some of the doctors do. I just can’t figure out why the radiologist won’t call me later today or maybe tomorrow. I have to wait until Monday to have my appointment with him.
FRIEND:  Well, you know ______ [the wife] has gone through this. Georgie, why don’t you play with Maxwell? They do everything by committee. I think it may have something to do with liability.
ME: Maxie–go ahead and play with George. What liability?
FRIEND: Well, they probably want to consult with their colleagues and make sure that they do everything as carefully as possible. With ______ so many people contributed to her current well-being–they all want to be super careful. Also, you know, if the scan is ambiguous or something….
ME: Well, he said there would probably be not much change. It has been three months since the last radiation treatment. Uh-oh, here comes this black dog with four white feet. He’s a puppy. Maxwell loves to play with him. I want to go back to “not much change.” I think there must be no more forests left standing in the world.
FRIEND: What?
ME: I have been knocking so violently on so much wood, and it would be a good thing if there was not much change, nothing new, so I have to knock wood again right now.
FRIEND: (Laughs) Why not much change?
ME (leaning over to push Maxwell into contact with the black white-footed puppy): Evidently–that’s it, Maxie! Play with that dog. Wear yourself out–it takes a while for the vacuum cleaner to come through and clean up after the radiation mess, or something like that. Like months. The CT scan next October will be more significant. Unless, of course, some monstrous thing like from “Alien” has suddenly started growing in there during the last three months. (Puppy, on her back, squeals.) Maxwell, do not chew on that dog’s neck. Like he really understands.
FRIEND: Well, let me know.
ME: I will. How is _______ doing?
FRIEND:  She started interferon-triple-cocktail. She has to take it once a week. And she has to go over to 70th and York every day
ME: Every day?
FRIEND: For a blood test. Yes, there is this one-hour window three times a day during which she has to take this new drug which is experimental in post-transplant patients. And with it, she has to eat something with twenty ounces of fat. Three times a day!
ME: Mmmmm! That’s not so bad. What’s she using?
FRIEND: Haagen-Dazs.
ME: Yum.
FRIEND: She doesn’t have to go over there for the interferon. She gives herself her own injection.
ME: Hey, Maxie–don’t be so rough. He’s being rough. Maxwell, come here. I said come here. Do you want a treat? (Maxwell comes over.) I’m putting you on the leash. Why didn’t you play with George here? (I push him once again toward George, who growls ominously.) Never mind. I guess it’s time to go.  So remind me when ______’s cancer was diagnosed?
FRIEND: Oh, it wasn’t liver cancer. Come on, George–I guess we’ll go too.
ME: Really?
FRIEND: Nope–Hep C! I guess she did have cancer by the end, but I don’t like to say she had it, because I’d rather she didn’t. But she’ll say she had cancer.
ME: Eh?
FRIEND: Well, she actually did. When you’re in the end stage of Hep C, your liver has got much wrong with it that it has everything, and cancer was a part of that. It also moved her up the transplant list.
ME: But she’s feeling all right now?
FRIEND: Yes.  But the side effects of interferon are cumulative, and she has to take it for a year!
ME: That’s tough. I can’t imagine.

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